||Parkland Chief BASIC TOPICS SECTION A. NEURORADIOLOGYUNIT OBJECTIVES
Demonstrate an understanding of neuroradiological imaging and interventions as they specifically relate to neurosurgical patients. COMPETENCY-BASED KNOWLEDGE OBJECTIVES
Review the indications for interventional endovascular therapies for:
COMPETENCY-BASED SKILL OBJECTIVES:
aneurysms vasospasm cranial vascular malformations spinal vascular malformations tumor embolization carotid and vertebral stenosis carotid and vertebral dissection
Describe the indications and techniques of endovascular trial occlusions. Review the role of quantitative cerebral blood flow studies in the management of neurosurgical patients. Describe the concepts of positron emission tomography. Review the indications for obtaining such scans. Describe the concepts of functional MR imaging. Review the indications for obtaining such scans. Describe the concepts of MR spectroscopy. Review the indications for obtaining such evaluations in neurosurgical patients. Discuss the indications and technique of discography. Describe the procedure.Discuss the indications for percutaneous vertebroplasty. Describe the procedure
Demonstrate the ability to accurately interpret radiological examinations of neurosurgical patients. Demonstrate the ability to use intraoperative ultrasonography
B. GENERAL CRITICAL CAREUNIT OBJECTIVES
Demonstrate an ability to triage neurosurgical patients to and from a critical care setting. Demonstrate a knowledge of and the ability to manage neurosurgical patients in the critical care setting. COMPETENCY-BASED SKILL OBJECTIVE:Oversee and direct the junior and middle level resident management of critically ill neurosurgical patients C. PRACTICE MANAGEMENT, LEGAL AND SOCIOECONOMIC ISSUESUNIT OBJECTIVES
Demonstrate an understanding of the principles of practice management and the business aspects associated with the delivery of health care. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Review the requirements to obtain certification from The American Board of Neurological Surgery. Discuss the available opportunities to obtain continuing medical education credits. Describe the political, economic, and social factors which impact on the practice of medicine generally and neurosurgery specifically. Demonstrate a working knowledge of the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) coding and analysis. Discuss the concept of relative values units (RVUs). Summarize the process of impairment determination as it relates to the neurosurgical patient population. Review the availability, requirements, and application procedures for post-residency fellowship if appropriate. Discuss the following issues as they relate to planned neurosurgical practice:
maintenance of the clinical record review and documentation of morbidity and mortality risk management Discuss the theory and organization of CPT coding, along with examples of complex procedural coding. Describe the considerations in Evaluation and Management (E & M) coding, including documentation requirements. Describe the work, practice expense, and malpractice expense components of Medicare's Resource-based Relative Value Scale (RBRVS) and how they are derived. Explain how Medicare and commercial payer conversion factors are derived and used to create a fee schedule from the RBRVS. Describe commonly used methods of physician risk contracting, such as capitation payment, and explain the considerations in negotiating such a contract. Describe the practice information necessary to safely and profitably manage a neurosurgical risk contract. Review the features, similarities, and differences in various third party payment systems including:
healthcare delivery systems, including managed care health care economics political and legislative processes in healthcare
Obtain a demographic profile of potential practice locations to include population and medical demographics. Outline the essential business characteristics of neurosurgical practice including:
content and interpretation of financial reports management of human resources facility design and maintenance billing and collection processes
Discuss the key elements of a provider professional services agreement, such as a PPO or HMO contract, and identify provisions that require particular attention. Describe the typical provisions and considerations in a physician employment contract including what to look for and what to avoid. Describe, compare, and contrast partnership versus corporate practice structures, including the tax and liability advantages and disadvantages of each. Describe the advantages and disadvantages of solo, single specialty group, and multispecialty group practice. Review the financial issues associated with the neurosurgical career options under consideration. Describe the administrative structures and processes required for managing an office practice including:
billing and collection for medical services financial accounting and reporting scheduling transcription medical record management appointment scheduling information system facility selection and maintenance secretarial services
Describe the content, interpretation, and utilization of the following financial documents:
balance sheet income and expense statement accounts payable and receivable collection analysis
Discuss the insurance requirements associated with neurosurgical practice including:
personal and professional liability personal health and disability casualty, fire, and theft personal life
Discuss the issues of quality assurance as related to neurosurgical practice including:
COMPETENCY-BASED SKILL OBJECTIVES:
Medicare Medicaid commercial insurance worker's compensation
Contrast HMO and PPO health plans. Describe the meaning of "managed care" and its typical components including:
contractual discounts provider risk arrangements utilization management provider report cards practice guidelines restricted access models
List and discuss the ethical issues and conflicts of interest involved in managed care treatment decisions such as:
primary gatekeeper point of service open access
capitation reimbursement risk pools cost saving incentive bonuses
Discuss antitrust considerations faced by physicians in payer contract negotiations including the concepts of collective bargaining, price fixing, and group boycott. Describe types of retirement plans and funding considerations and limitations. Explain the differences between occurrence and claims-made professional liability insurance and considerations made in selecting insurer and coverage levels.
Demonstrate the ability to properly code neurosurgical activities. Accurately assign and justify medical impairment ratings for neurosurgical patients. Outline a post-residency career track. Apply for post-residency fellowship if appropriate. Obtain information about specific practice, research, or administrative career opportunities as appropriate.Compose a list of questions to ask and things to see when interviewing for a neurosurgical position. Read and interpret a financial report. Design a structure for an office practice including a listing of the generic office processes and how to arrange staffing. Prepare lists of neurosurgical instruments/equipment needed for specific operative procedures. Select a proper practice, research, or administrative opportunity if appropriate. Complete license and registration requirements for your chosen location. Complete applications for hospital staff membership and clinical privileges. Complete resident case data sheet for the American Board of Neurological Surgery and have same signed by Program Chair.
NEUROSURGICAL CLINIC TOPICS SECTION D. CEREBROVASCULAR SURGERYUNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology and presentation of cerebrovascular diseases, including ischemic and hemorrhagic stroke, and other diseases and malformations of intracranial, extracranial, and spinal vasculature. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for cerebrovascular diseases, including medical and surgical management. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Demonstrate a sophisticated understanding of current literature related to basic neuroscience knowledge objectives acquired as a junior and middle resident. Define scientific hypotheses in relationship to controversies and evolving knowledge regarding these same objectives and demonstrate the ability to interpret and adapt new knowledge to evolving patient-care paradigms. Demonstrate a mature fundamental knowledge in clinical and teaching conferences, specialty conferences, and in publications and scientific presentations. Understand the guidelines, protocols, and literature controversies regarding the diagnostic imaging modalities available in cerebrovascular disease.
COMPETENCY-BASED SKILL OBJECTIVES:
Review fundamental concepts of cerebrovascular disease during conferences and clinical rounds with the house staff and medical student. Demonstrate a mature clinical judgment related to the spectrum of problems encountered in hemorrhagic and ischemic stroke states. Formulate independent plans for patient assessment and management, including prioritization in cerebrovascular disease while maintaining a clear reporting relationship with faculty. Supervise house staff and medical student team in daily patient assessment and care. Identify the indications and controversies of endovascular catheter procedures, perioperative management, and follow-up. Implement and supervise patient care protocols related to these procedures. Display a mature and detailed understanding of indications, principles, and interpretation of the full spectrum of neurodiagnostic armamentarium. Formulate independent management plans based on sophisticated interpretation of diagnostic studies for concise presentation to faculty. Apply evolving technology and new methods to patient protocols and the education of house staff and medical students. Demonstrate a mature understanding of surgical strategies and approaches to common and unusual vascular disease. Apply the principles of intraoperative anesthetic management, proximal and distal control, temporary arterial occlusion, brain protective strategies, and intraoperative localization as applied to vascular disease. Complete the planning, positioning, and execution of pterional craniotomy for common vascular disease. Perform microsurgical dissection of the Sylvian fissure and exposure of the basal cisterns for vascular disease. Perform microsurgical exposure and clipping of intracranial aneurysm. Complete the planning, positioning, and execution of non-pterional craniotomy for intracranial vascular disease. Assist in the microsurgical management of highly complex cerebrovascular disease. Plan and execute the craniotomy for the evacuation of intracranial hematomas. Supervise other house staff in meeting their surgical objectives. Describe the exposure and treatment of intraspinal vascular lesions. Assist in such operations. Oversee all aspects of patient care, identification of appropriate cases for database analysis, morbidity, mortality, conferences, and discussions. Supervise medical students and house staff in every aspect of patient care. Report appropriate patient care issues to responsible faculty members in a timely fashion. Organize and administer teaching conferences. Display mature participation in specialty conferences. Assign responsibilities to junior residents and residents, with the aim of fulfilling their respective educational objectives
E. NEUROSURGICAL ONCOLOGYUNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of tumor-related diseases of the cranium. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for tumor-related diseases of the cranium that are amenable to surgical intervention. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe the indications for transcranial orbitotomy and list the lesions which require this approach. Discuss the surgical management and postoperative treatment of astrocytomas, gliomas other than astrocytomas, metastatic brain tumors, infectious granulomas, and cystic lesions presenting in a tumor-like manner. Review the role of radiotherapy, chemotherapy, and other adjunctive treatments of these neoplasms. Describe the role of surgery for intracranial meningioma, and the relation between the surgical option and location of tumor. Discuss adjuvant treatments of meningioma and their efficacy. Discuss the surgical treatment of common intrinsic posterior fossa neoplasms, including cerebellar astrocytoma, medulloblastoma, and ependymoma including the role of ventricular drainage, and surveillance imaging. Present adjuvant treatment options and outcomes for the various posterior fossa intrinsic tumors. Address the surgical goals of treatment, complications of surgical treatment, and adjuvant therapy for posterior fossa meningioma. List and illustrate the various approaches for removal of a vestibular schwannoma, and the rationale and indication for each approach. Describe the role of stereotactic radiosurgery and microsurgery in the management of vestibular schwannoma. List the various approaches to the midline clivus and review the indications for each approach. Outline the surgical and medical management of tumors of the clivus and midline skull base. Explain the management goal for a patient with craniopharyngioma, and the risks of surgical treatment and conservative treatment. Describe the various surgical approaches used to resect craniopharyngiomas and the options for adjuvant treatment, including radiotherapy and chemotherapy (systemic and local). Illustrate the transnasal-transphenoidal approach and its indications. Define the options for treatment of recurrent pituitary tumors of all types (including medical management). Describe the risks of the approach and the management of the complication of CSF leak. Illustrate the various skull base approaches to the anterior, middle and posterior cranial fossae in detail, explaining the key anatomical landmarks and strict indications for the approach. List the complications relevant to each approach and the management of each complication. List a differential diagnosis of orbital tumors, their usual location within the orbit, medical and surgical management of the tumor and the approach used to remove the tumor if indicated. List the various tumors and their location in which an orbitocranial approach may be indicated for their removal. Compare and contrast the exposure offered by the pre-and postauricular infratemporal approach, and the indications for each approach. Illustrate transposition of the facial nerve during a transtemporal skull base approach. Describe the location of meningiomas intracranially which are amenable to preoperative embolization.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Demonstrate the capability to function independently in all phases of management of patients with intracranial neoplasms. Perform resection of supra- and infratentorial intra-axial and extra-axial neoplasms. Perform resection of pituitary lesions. Perform or serve as first assistant for skull base procedures. Oversee the pre- and postoperative management of patients with intracranial neoplasms. Assume teaching responsibilities for junior residents as assigned. Assume responsibility for managing the pyschosocial aspects of intracranial neoplasms.
F. NEUROTRAUMA AND NEUROSURGICAL CRITICAL CAREUNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of traumatic injuries of the brain, spinal cord, and peripheral nervous system, including their supporting structures. Demonstrate the ability to formulate and implement appropriate diagnostic and treatment plans for traumatic injuries to the nervous system, including both surgical and nonsurgical management. COMPETENCY-BASED KNOWLEDGE OBJECTIVE:
Discuss management priorities in polytrauma patients with severe neurological and systemic trauma.
COMPETENCY-BASED SKILL OBJECTIVES:
Perform the above procedures (listed under #1 for "A Middle Level" in complicated cases. Reconstruct complex cranial defects, with assistance from other specialties as indicated. Reconstruct traumatic skull base defects, with assistance from other specialties as indicated. Explore and repair peripheral nerve injuries. Supervise and teach junior and middle level residents with cases appropriate for their level. Lead the critical care team in the treatment of patients with neurological injuries, either in isolation or in polytrauma patients.
G. SPINAL SURGERYUNIT OBJECTIVES
Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of disorders of the spine, its connecting ligaments, the spinal cord, the cauda equina, and the spinal roots. Demonstrate the ability to formulate and implement a diagnostic and treatment plan for diseases of the spine, its connecting ligaments, the spinal cord, the cauda equina, and the spinal roots that are amenable to surgical intervention. COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
Describe indications for the use of angiography and endovascular procedures in the management of spinal disorders. Discuss the management of cervical degenerative disease secondary to rheumatoid arthritis. Describe factors which make it different from the management of non-rheumatoid disease. Compare and contrast the treatment options for cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, including multilevel anterior cervical corpectomy and fusion, laminectomy, laminectomy and fusion, laminoplasty, and nonoperative therapies. Discuss the indications for posterior cervical spinal internal fixators. Compare and contrast the transthoracic, transpedicular, costotransverse, and lateral extracavitary approaches to a herniated thoracic disc, thoracic tumor, or thoracic spinal injury. Discuss the indications for lumbar fusion for congenital disorders, iatrogenic disease, and degenerative disease, ranking indications from least to most controversial. Compare and contrast the indications for anterior or posterior lumbar interbody fusion and intertransverse fusion for lumbar disease. Discuss internal fixation options for posterior lumbar interbody fusion and intertransverse fusion. Summarize the most common types of spinal tumors in the following categories:
COMPETENCY-BASED SKILL OBJECTIVES:
Discuss nonoperative and operative treatment options for fractures and dislocations affecting the atlas and axis. Compare and contrast the indications for nonoperative treatment, anterior approaches, and posterior operative approaches for the treatment of fractures and dislocations of the subaxial cervical spine. Describe the indications for anterior, posterior, and posterolateral procedures in the management of thoracolumbar tumor, trauma, or infection. Compare and contrast the indications for anterior and posterior spinal fixators in the management of thoracolumbar tumor, trauma, or infection. Discuss reconstruction options for vertebral body defects after corpectomy for tumor, trauma, or infection.
Demonstrate the ability to function independently in all phases of management of patients with spinal disorders. Demonstrate the ability to perform occipital-cervical arthrodesis. Demonstrate the ability to properly place sublaminar wires, lateral mass screws, lower cervical/upper thoracic pedicle screws, C2 pars interarticularis screws, and C1-2 transarticular screws for the management of cervical spine disorders. Demonstrate the ability to perform, with assistance if necessary, transoral odontoidectomy. Demonstrate common techniques for performing C1-2 arthrodesis. Demonstrate the ability to perform anterior cervical corpectomy followed by arthrodesis. Demonstrate the ability to perform, with assistance if necessary, transthoracic, thoracoabdominal, retroperitoneal, and transabdominal approaches to the thoracic and lumbar spine. Demonstrate the ability to perform costotransverse and lateral extracavitary approaches to the thoracolumbar spine. Demonstrate the ability to excise a herniated thoracic disc by use of the above-mentioned approaches. Demonstrate the ability to perform vertebral corpectomy of the thoracolumbar spine for tumor, infection, or trauma, utilizing the above-mentioned approaches. Demonstrate the ability to perform anterior arthrodesis of the thoracolumbar spine. Demonstrate the proper placement of transpedicular screws in the thoracic and lumbar spine. Demonstrate the proper placement of laminar, transverse process, and pedicle hooks in the thoracic and lumbar spine. Demonstrate the ability to resect intradural spinal neoplasms. Demonstrate the ability to perform methylmethacrylate vertebroplasty. Demonstrate techniques of open reduction of fractures and dislocations of the cervical, thoracic, and lumbar spine. Demonstrate the ability to surgically manage arachnoid cysts and spinal cord syrinx. Demonstrate the ability to perform intradural procedures for congenital, neoplastic, and vascular lesions.
Last Updated Feb 2013